Provider Demographics
NPI:1144638776
Name:TICKNOR ENTERPRISES HICO ALF, LLC
Entity type:Organization
Organization Name:TICKNOR ENTERPRISES HICO ALF, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:TICKNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-269-3375
Mailing Address - Street 1:100 S. WALNUT
Mailing Address - Street 2:
Mailing Address - City:HICO
Mailing Address - State:TX
Mailing Address - Zip Code:76457-0000
Mailing Address - Country:US
Mailing Address - Phone:254-796-2582
Mailing Address - Fax:254-796-2151
Practice Address - Street 1:100 S. WALNUT
Practice Address - Street 2:
Practice Address - City:HICO
Practice Address - State:TX
Practice Address - Zip Code:76457-0000
Practice Address - Country:US
Practice Address - Phone:254-796-2582
Practice Address - Fax:254-796-2151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000998OtherDADS FACID#